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… Pushing back on pills

As Indiana faces up to a crisis of prescription medicine abuse, a state task force is …

McMahan
Zoeller

For a variety of reasons, Indiana is particularly challenged in the national battle against prescription drug abuse.

Among those fighting back are Dr. Deborah McMahan, Allen County's health commissioner. So is Dr. Daniel Roth, a Fort Wayne pain-management specialist, whose column below addresses some of the reasons prescription drug abuse is so hard to control.

Along with Attorney General Greg Zoeller and other members of the state's Prescription Drug Task Force, McMahan and Roth are trying to change the way doctors – and their patients – deal with pain. They need our help.

Roth says medical schools and residencies have taught doctors to respond to their patients' pain but really haven't taught them alternatives to painkillers.

“A lot of times, they're not sure what to do with a patient, and that's when they prescribe Vicodin, Percocet or whatever,” Roth said.

“There was so much focus on pain management,” said Zoeller, who co-chairs the task force. “So they flooded the market with (pills).”

There was always the danger that some patients could become dependent or even addicted. More often, the drugs were ending up in the hands of others who misused them. Kids took their parents' pills and shared them at “pharma parties.” Drug dealers sold them along with traditionally outlawed drugs.

The results were car accidents, lost work time, emergency room visits and – often – overdose deaths.

“It's just not working,” McMahan said of the overprescribing phenomenon. “It's not good for the individual and it's not good for the community.”

Zoeller became aware of the dimensions of the problem when his office began conducting symposiums on prescription drugs five years ago. Every year, more medical and law enforcement representatives attended, desperate for answers. Last year, “the number of people flooding in got everybody's attention,” Zoeller said.

There may be several reasons Indiana faces a particularly acute problem. One, Zoeller said, stems from Florida's crackdown four years ago on “pill mills” that had been a mecca for opioid users. After that, demand spiked in several other states, including Indiana. “We probably are still dealing with the consequences of those problems,” Zoeller said.

Some of the measures that other states had used to limit painkiller distribution were not in place in Indiana, and the results were demonstrable:

• The state is fifth in prescription-drug deaths among people 12 or older, Zoeller's office says.

• A recent report from the Centers for Disease Control and Prevention showed that, in 2012, Indiana doctors issued 109 painkiller prescriptions per 100 Hoosiers. During the same year, doctors in Illinois issued 68 per 100 residents.

•All that added drug availability pushed Indiana's overdose death rate to 14.4 per 100,000; Illinois' rate is 10. The majority of those deaths are from prescription drugs.

• Zoeller says the number of pharmacy robberies in Indiana has led the nation and offers further evidence of prescription-drug addiction.

Created in 2012, the Indiana task force began to close the loopholes and remedy the lack of awareness that had made Indiana prime territory for “legal” drug abusers.

The task force wasn't formed, Zoeller said, just to “do a study.”

The approach was, “it's an epidemic – we need to act.”

On the task force's recommendation, last year's legislature passed a requirement that anyone who runs a pain clinic has to be a licensed physician.

The state lowered the boom on physicians who were clearly going beyond routine treatment. “There were doctors writing thousands of prescriptions a month,” Zoeller said. “We brought them before the medical board and had their medical licenses revoked.”

Perhaps most crucial was the effort to get doctors to think differently. New rules suggested by the task force and being enacted by the state Medical Licensing Board are aimed at getting doctors to look further before prescribing a painkiller. Doctors are now required to check online to make sure their patients aren't getting the same prescription elsewhere. They're asked to have their patients complete a pain assessment and a drug-screening test and to evaluate the patient's mental health status and risk for addiction. When they prescribe opioid painkillers, doctors are asked to monitor their patients' progress regularly and to refer them to a specialist if their use reaches a high enough level.

“I'm hopeful that's going to have a positive effect,” McMahan said last week. “It implies a different approach than merely prescribing pills.”

When Roth talked with me Wednesday, he was on his way to yet another meeting with doctors to explain some of the techniques they can use beyond prescription drugs. On behalf of the task force, he said, he's met with 30-40 doctors in the past year.

There are times when giving a patient opioids may be the only solution, he said. But there are ways to provide relief without resorting to pills that may build dependence or addiction or strain a patient's system as they work their way through the body, he said.

“The most important thing,” Roth said, “is to diagnose the pain-generator.” A doctor applying Roth's approach might use an ultrasound to inject a steroid into the center of the problem area. Then the doctor might use a patch to deliver NSAIDs or muscle relaxants directly to the area that's hurting – on the shoulder of a bursitis patient, for instance.

“There are a lot of options,” Roth said.

Other initiatives the task force is pushing include making it easier to dispose of unused medicines and distributing an opioid-OD antidote and training a wide range of people on its use. Part of the reason for that, Zoeller said, is that as painkillers have become harder to get, heroin use has increased dramatically.

The task force is also trying to augment resources to treat addiction.

“The medical communities are just outnumbered,” Zoeller said. “We don't have enough people to treat the number of people addicted.”

The attorney general and his office have been in the forefront of the bring-painkillers-under-control effort, but he prefers to call the task force a cooperative endeavor with branches of state, local and national governments.

Zoeller gives much of the credit to task force members such as Roth and McMahan, who chairs the task force's education committee.

Doctors, not task forces, are the only ones who can see that the oversupply of painkillers is brought under control. But McMahan, for one, believes the group's efforts are beginning to resonate.

She wants the rest of us, as patients, to understand that doctors can't always solve everything with a pill. “People come in with an expectation that I'm going to be pain-free when I come out.”

But there may be better ways for doctors to help you cope with pain over the long term.

“Certainly we don't want people to suffer,” McMahan said. But she wants doctors to “think that their whole approach isn't just to manage pain but to improve function.”

“It really is about reclaiming our profession.”

Tim Harmon is an editorial writer for The Journal Gazette.

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